Precise Localization of a Bile Leak with Hepatobiliary Scintigraphy

Abstract

Hepatobiliary scintigraphy (HBS) is a widely used modality to diagnose biliary injury. In patients with a history of trauma or surgery, the common presentations of bile leaks on HBS are a progressive collection of radiotracer outside the biliary system. However, the precise localization of a bile leak is usually not conveyed by noninvasive techniques including CT or ultrasound or even HBS. This case study of a patient with liver trauma demonstrates a direct bile leak sign leading to recognition of an exact bile leakage site from the left intrahepatic duct. This diagnosis helped clinicians perform less-invasive management. Hepat obiliary scintigraphy (HBS) is a widely used modality to diagnose biliary injury (1). In patients with a history of trauma or surgery, the common presentations of bile leaks on HBS are a progressive collection of radiotracer outside the biliary system (2). However, the precise localization of a bile leak is usually not conveyed by noninvasive techniques including CT or ultrasound or even HBS (3,4). CASE REPORTA 16-y-old male (who along with his parent gave permission to use the data from his studies for our article) presented with injuries from a motor vehicle accident. A CT scan of the abdomen/pelvis with contrast demonstrated central hepatic laceration with extension into gallbladder fossa and peritoneal fluid. HBS was required to determine whether a biliary injury was present or not.After intravenous administration of 99m Tc-mebrofenin, sequential dynamic abdominal images were obtained over 60 min (Fig. 1). Images showed an area with decreased activity over the region between the 2 hepatic lobes, corresponding with the known hepatic laceration seen on the CT (Fig. 2). Over time, there was a progressive accumulation of tracer outside the biliary system over the inferior left hepatic lobe. A couple of lines of tracer uptake connected this abnormal focal area to the left intrahepatic duct. Eventually, this abnormal tracer accumulation spread throughout the abdomen. These findings indicated an exact bile-leaking site at the left intrahepatic duct.Subsequently an endoscopic retrograde cholangiopancreatography with initial cholangiogram confirmed the findings of the HBS (Fig. 3). Sphincterotomy and placement of 2 common bile duct stents were performed. Soon after, a diagnostic laparoscopy further confirmed a bile leak from the left hepatic duct, and a laparoscopic lavage and intraperitoneal drainage were performed. The patient did well postoperatively and was discharged with no extravasation of contrast in the follow-up endoscopic retrograde FIGURE 1. HBS over 60 min shows area with decreased activity over region between the 2 hepatic lobes, corresponding with known hepatic laceration seen on CT (black arrow). Over time, there is a progressive accumulation of tracer outside the biliary system over inferior left hepatic lobe (pink arrow). A couple of lines of tracer uptake (red arrows) connected this abnormal focal area to left intrahepatic duct. Eventually, this abnormal tracer accumulation ...

Biliary Leaks and Bilomas: Etiology, Diagnosis, and Management Techniques

“…3 ). 50 The magnitude of the leak may also be assessed based on the quantity of tracer that has exited the biliary system into the perihepatic space. While useful in confirming a leak, cholescintigraphy is limited in its spatial resolution, making it challenging to identify the precise location of the leak.…”

Hepatobiliary scintigraphy and its clinical implications: mini review

“…He had central hepatic laceration with extension into gallbladder fossa and peritoneal fluid, who underwent Hepato-biliary scintigraphy (HBS). 9 The report concluded that although the precise site of a bile leak is often difficult to detect with noninvasive techniques, it is possible with HBS.…”